2025 CPT code 25515

Open treatment of radial shaft fracture, includes internal fixation, when performed.

Refer to CPT guidelines for proper coding of fracture treatments and internal fixation. Ensure accurate documentation of the fracture and treatment method.

Modifiers may be applicable in certain situations, such as increased procedural services (22), bilateral procedures (50), or surgical care only (54).

Medical necessity for this procedure must be established by demonstrating that the fracture is unstable, significantly displaced, or involves other injuries requiring surgical intervention.

The physician prepares the patient and administers anesthesia. Then, they make an incision over the fractured radius, reduce (realign) the fracture, and use internal fixation if necessary. Imaging is used to confirm proper alignment, and the incision is closed after irrigation and hemostasis. A splint or cast is applied for immobilization.

In simple words: The doctor treats a broken bone in your forearm (radius) with surgery. They make a cut to reach the broken bone, put the pieces back together, and may use metal hardware like plates and screws to hold it in place while it heals.

This code describes an open surgical procedure for treating a fracture of the radius shaft (the long bone in the forearm). The procedure involves making an incision to access the fracture, realigning the bone fragments (reduction), and stabilizing the fracture using internal fixation devices like plates, screws, or pins, if necessary.

Example 1: A 25-year-old male sustains a displaced radial shaft fracture in a motorcycle accident. Open reduction and internal fixation with plates and screws are performed to stabilize the fracture., A 60-year-old female falls and suffers a comminuted radial shaft fracture. Open reduction and internal fixation with an intramedullary nail is performed., A 10-year-old child falls from a tree and fractures their radial shaft. Open reduction is performed, and the fracture is stabilized with K-wires due to the growing nature of the bone.

Documentation should include details of the fracture, type of reduction, method of fixation, intraoperative findings, and any complications. Pre- and postoperative radiographic images should also be included.

  • Specialties:Orthopedic Surgery
  • Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Outpatient Hospital
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